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Based on observation and interview, the provider failed to maintain egress paths free of hazards for two of five exits (housekeeping/linen area and lower level recovery area). Findings include:

1. Observation at 3:30 p.m. on 5/20/19 revealed the path of egress for the lower level recovery area (currently not used for patients) was obstructed by tables holding vendor/educational displays. Paths of egress must not be through hazardous locations. An exit enclosure shall not be used for any purpose that had the potential to interfere with its use as an exit and if so designated as an area of refuge. LSC 7.1.3.2.3

Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated he was unaware of the corridor display.

The deficiency had the potential to affect 100% of the smoke compartment's occupants.

2. Observation at 3:50 p.m. on 5/20/19 revealed the path of egress for the housekeeping/linen wing to the northeast exit was obstructed by carts. The carts contained combustible items (linen and housekeeping supplies) making the corridor a hazardous location. Paths of egress must not be through hazardous locations. An exit enclosure shall not be used for any purpose that had the potential to interfere with its use as an exit and if so designated as an area of refuge. LSC 7.1.3.2.3

Interview with the maintenance supervisor at the time of the observation confirmed that condition. He stated they are aware of the lack of space, but the quantities of both items are necessary for the operation of the hospital.

The deficiency had the potential to affect 100% of the smoke compartment's occupants.

Based on observation and interview, the provider failed to maintain egress paths free of hazards for two of two exits (east stairwell, and corridor access to west stairwell). Findings include:

1. Observation at 2:30 p.m. on 5/20/19 revealed the path of egress for the level two patient room corridor was obstructed by two large carts, a vacuum cleaner, and three computer carts. Paths of egress must not be through hazardous locations. An exit enclosure shall not be used for any purpose that had the potential to interfere with its use as an exit and if so designated as an area of refuge. LSC 7.1.3.2.3

Interview with the director of plant operations at the time of the observation confirmed that condition. He stated that this is an on-going challenge.

The deficiency had the potential to affect 100% of the smoke compartment's occupants.

Based on observation and interview, the provider failed to maintain one randomly observed hazardous area (clean linen storage room) as required. Findings include:

1. Observation at 3:50 p.m. on 5/20/19 revealed the clean linen storage room was over 100 square feet and had large amounts of combustible items stored in it. The corridor door from that room was held open by linen carts. The room size was inadequate to contain the number of linen carts.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for hazardous storage rooms and had the potential to affect 100% of the occupants of that smoke compartment.

Based on observation and interview, the provider failed to maintain conforming exit stairs (old employee exit and northwest stair by Operating Room 9 and Operating Room 10). Neither stairwell door used fire exit hardware. Items were stored in the old employee exit stair enclosure. An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. Findings include:

1. Observation at 2:30 p.m. on 5/20/19 revealed the crash bar used on the door to enter the old employee exit stair was not fire exit hardware. Within the exit enclosure a patient drape, a materials management cart, and an xray machine were stored in the stair enclosure at the basement level. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated he was unaware those items had been placed within the exit enclosure and that the crash bar was not fire exit hardware.

2. Observation at 8:00 a.m. on 5/21/19 revealed the crash bar used on the door to enter the exit stair near OR 9 and OR 10 was not fire exit hardware. Interview with the maintenance supervisor at the time of the observation confirmed those findings. He stated he was unaware the hardware was not fire exit hardware.

The deficiency affected two of three stair enclosures.

Based on observation, testing, and interview, the provider failed to maintain the necessary characteristic features for two of three sets of ninety-minute fire rated cross-corridor doors separating the operating rooms on first floor into three suites, the storage room door for the OR suites, and the fire door on the west side of the basement elevator vestibule. Findings include:

1. Observation, testing, and interview on 5/21/19 at 7:35 a.m. of the ninety-minute fire rated doors located at the operating rooms (ORs) with the director of plant operations revealed neither set of cross corridor doors met the separation distance for smoke containment. This had the potential to affect all persons within the three smoke compartments of the OR.

2. Observation, testing, and interview on 5/21/19 at 7:40 a.m. of the forty five-minute fire rated doors located at the operating rooms (ORs) storage room south door with the director of plant operations revealed the door did not latch and was not smoke tight. This deficiency had the potential to affect all persons within the three smoke compartments of the OR.

3. Observation, testing, and interview on 5/21/19 at 8:30 a.m. of the forty five-minute fire rated doors located at the basement elevator vestibule west side with the director of plant operations revealed the door did not latch. This had the potential to affect all persons within the smoke compartment.

Based on observation and interview, the provider failed to maintain unobstructed space adjacent to the sprinkler deflector so the water discharge was not interrupted in basement Central Sterilization Room (CSR) mechanical/boiler room used as storage area. Findings Include:

1. Observation beginning at 10:40 a.m. on 5/21/19 revealed three ceiling sprinklers in the CSR mechanical room. The room is labeled "boiler room", but in fact leads to the boiler room, and is separated from that room. Ductwork supply and return was at several levels within the room. The sprinkler discharge pattern would have been sufficient if the room was not used for flammable storage. However, available floor space was crowded with carts and patient care equipment. Interview with the director of plant operations at the time of the observation confirmed that finding. He stated the lack of storage space required available floor space to be used.

The deficiency affected one locations required to be equipped with unobstructed fire sprinkler protection.

Ref: 2012 NFPA 101 Section 19.3.5.1, 9.7.1